4.4 Viral infections

For clinical signs and diagnosis, refer to the MSF handbook Clinical guidelines.

4.4.1 Genital herpes

If the mother has visible herpetic lesions at time of childbirth:

– Limit vaginal exams; no artificial rupture of membranes.

– Discuss caesarean section on a case-by-case basis.

– For the mother:
• Pain management: paracetamol PO,1 g 3 times per day
• Antiviral treatment: aciclovir PO, 400 mg 3 times per day for 7 days
In immunocompromised patients, continue the treatment until symptoms resolve.
• Oral aciclovir prophylaxis (aciclovir PO: 400 mg 4 times per day from 36 weeks LMP and until delivery) can be proposed to reduce the risk of recurrent herpes at delivery.

– For the treatment of the newborn, see Chapter 10, Section 10.4.3.

4.4.2 Varicella (chickenpox)

There is a risk of severe maternal varicella pneumonia and severe neonatal varicella.

Aciclovir PO as soon as possible after the onset of rash (800 mg 5 times per day for 7 days) may reduce these risks7.

4.4.3 Hepatitis

Hepatitis B

Without intervention, mother-to-child transmission of the hepatitis B virus (HBV) is high (up to 90%).

– For the mother: no specific treatment; no special obstetric measures.

– For the newborn: hepatitis vaccination within hours after birth has been demonstrated to prevent 70 to 95% of infections. All infants should be vaccinated (Chapter 10, Section 10.1.8) regardless of the mother’s HBV status. In infants born to HBV-positive mothers, vaccination AND administration of hepatitis B immune globulin, if available (within 12 hours after birth), has been demonstrated to prevent 85% to 95% of infections8.

Hepatitis E

Hepatitis E carries a very high mortality rate for pregnant women (20% during the third trimester). It can cause spontaneous abortion, preterm delivery, and intrauterine foetal death.

The virus is acquired by fecal-oral route (primarily by drinking contaminated water). The virus can cause outbreaks, especially in situations where large numbers of people are gathered (refugees, displaced persons), when hygiene and sanitation are poor.

Management is focused on supportive care (good hydration, avoidance of hepatotoxic medications). Prevention (water, hygiene, sanitation) is the only protection against the disease.

4.4.4 HIV infection

Mother-to-child HIV transmission may occur at any time during pregnancy, labour, delivery and the breastfeeding period. With no intervention, the risk of transmission is approximately 15 to 25% and 20 to 45% if the child is breastfed9. This risk may be reduced to less than 5%.

Ante-natal care

HIV-infected pregnant women need antiretroviral therapy regardless of their CD4 count and clinical stage. The treatment should start as soon as possible, regardless of gestational age and should be taken during all the pregnancy.

Intra-partum care

– Offer voluntary counselling and testing on admission if HIV status is unknown.

– Administer antiretroviral therapy at onset of labour and during delivery, as indicated in specialized Prevention of Mother-To-Child Transmission (PMTCT) guidelines.

– Observe standard precautions to avoid contact with blood and body fluids.

– Avoid:
• prolonged labour;
• prolonged rupture of membranes;
• early artificial rupture of membranes;
• invasive procedures such as episiotomy or instrumental delivery. However, they must be performed if they are necessary for delivering the child.

– The criteria for induction of labour are the same as for non HIV-infected women.

– Clamp umbilical cord immediately.

– Administer antiretroviral prophylaxis to the newborn immediately after birth.

– Prevention and treatment of postpartum haemorrhage: as for non HIV-infected women. However ergometrine or methylergometrine should not be used in women taking antiretrovirals unless alternative treatments (oxytocin or misoprostol) are not available. In this case and if the need for pharmacologic treatment outweighs the risks, ergometrine/methylergometrine should be used in low a dosage and the duration of treatment should be as short as possible.

A planned caesarean section can be beneficial if the viral load is detectable. However, given the risks associated with the intervention (surgical, anaesthetic and infectious) and the risk of uterine rupture during subsequent pregnancies, caesarean section is not recommended routinely.

Post-partum care

– Offer voluntary counselling and testing if HIV status has not been determined before.
– Continuation of antiretroviral therapy for the mother, at least during breast-feeding, or for life, depending on the situation.
– For the newborn: antiretroviral prophylaxis to the newborn as indicated in PMTCT guidelines.